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Blank No. 34 Series II. Form B. 2.

(continued) 4 - Number of children? number reachng maturity?

Your Paternal Grandmother: home in city or country?

1 - age when married?

2 - Occupations?

3 - health?

4 - Age and cause of death?

Your Mother: 1 - Nationality, if American of what descent?
What child of her parents, 1st 2d or 3d Etc.

2 - home in city or country after marriage?

3 - Occupations before her marriage?
b) after her marriage?

4 - Note any prenatal influences before your birth.

5 - her health previous to your birth?
b - after your birth?

6 - Number of miscarriages?

7 - Her age if living and present health? if not, age at time
of death and cause?

8 - how was your mother's health affected by the climacteric
(change of life).

9 - name any diseases in her family.

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